Provider Demographics
NPI:1629378344
Name:SERGIO J CABRERA PL LLC
Entity Type:Organization
Organization Name:SERGIO J CABRERA PL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMPARO
Authorized Official - Middle Name:S
Authorized Official - Last Name:CABRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-398-8940
Mailing Address - Street 1:4100 S FERDON BLVD SUITE A4
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536
Mailing Address - Country:US
Mailing Address - Phone:850-398-8940
Mailing Address - Fax:850-398-8943
Practice Address - Street 1:4100 S FERDON BLVD
Practice Address - Street 2:SUITE A4
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5252
Practice Address - Country:US
Practice Address - Phone:850-398-8940
Practice Address - Fax:850-398-8943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069027207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254367200Medicaid
FL254367200Medicaid